1 The natural world and human influences work together to create the devastation that follows a major 2 disaster such as a hurricane. Although many studies have examined broad patterns of effects on 3 pregnancy outcomes after disasters, the causes of adverse outcomes are not always clear, as there 4 are interrelated environmental pollutant exposures, psychological stressors, and lack of health care. 5 Without understanding which aspects of disaster exposure are the strongest contributors to adverse 6 outcomes, it will not be possible to establish disaster responses that efficiently target the most 7 important factors. The objective of this application is to examine effects of environmental (harmful algal 8 bloom, carbon monoxide) exposures and generally encountered disaster exposures (power outages, 9 storm damage) on pregnancy-related outcomes. Our central hypothesis is that severe exposure 10 (defined by both magnitude and duration) to any of these stressors will be associated with worse 11 outcomes. Our specific aims are to 1) Examine the relationship between environmental exposures 12 (HAB and CO) and birth outcomes; 2) Assess the relationship between general disaster-related 13 exposures (extent of damage, health care closings) and birth outcomes; 3) Determine which disaster- 14 related exposures most strongly predict birth outcomes, and the combined effect of environmental and 15 general disaster exposure; 4) Engage primary care practitioners to build EOH knowledge and skills by 16 developing CME content on HAB and CO. We will accomplish these specific aims by comparing birth 17 outcomes in areas exposed to these environmental predictors to areas and times that are unexposed. 18 We will map exposure patterns based on ecological sampling and satellite-based estimates (HAB), CO 19 surveillance data and poison control centers data, and hurricane damage reports (state of the art 20 satellite measurements, disaster declarations, power outage data, health facility closing) and physical 21 impacts measurements (storm surge inundation, wind speed, land cover change). Comparisons will be 22 made across and within areas exposed to different levels of environmental contaminants, as well as 23 pre-post hurricane. To promote translation and dissemination, we will develop CME content targeting 24 the potential risks adverse pregnancy and birth outcomes associated with exposures to HAB and CO. 25 At the end of the project, our expected outcome is to have identified the aspects of Hurricane Michael 26 most associated with adverse birth outcomes. The proposed research represents a three-pronged 27 innovative design- conceptually, by determining the potential cumulative risk of two integrated exposure 28 domains - environmental contaminants and traditional disaster; methodologically, by using Synthetic 29 Aperture Radar data to examine exposures to HAB during pregnancy in humans; and 3) translational, 30 by utilizing time sensitive disaster-related environmental health findings for frontline CME.